Skip to main content

Outcomes of Surgery in Older Persons: How Could We Know So Little?

About half of all operations performed in the United States are performed on persons over the age of 65. So you would think that there would be tons of research to help us guide patients as they ask us questions about how their health will be impacted by an operation. But we know very little. As far as evidence-based medicine is concerned, surgery in the elderly is an evidence-based wasteland.

How will an 85 year old with severe knee arthritis do after a joint replacement? One reason that this question is so hard to answer is that 85 year olds are so different. This question can not be answered generically. Some are highly active, while others (even if they had good knees) are disabled physically and/or cognitively. We suspect functional factors like these are likely to have huge impacts on surgical outcomes, but there is almost no data to guide us.

And we even lack the most basic evidence to address the older patient's "How will I do after surgery" question. Most of the information we have is on rates of death and surgical complications such as post-operative pneumonia. Of course these are important, but when the older patient asks, "how will I do" often what they are really asking is "How long will it be before I get back to normal?" "How long will I have trouble taking care of myself and be dependent on family caregivers?" "How long will my thinking be abnormal after surgery?" "How long before I can climb up the flight of stairs to my home?" "I know death is a rare complication, but how often will I suffer a permament loss in my ability to function independently?"

The honest answer to these questions: "WE DON'T KNOW."

In the New Old Age blog, Paula Span reports on an important study that breaks useful ground in starting to address these important questions. Led by Dr. Martin Makary, a surgeon at Johns Hopkins Hospital, the study proves that easy to measure markers of the patient's functional status strongly predict outcomes after surgery in older patients.

Markary used a 5 item frailty score (Weight loss, poor grip strength, exhaustion, low physical activity, decreased walking speed). The number of these measures on which a patient was frail strongly predicted outcomes after surgery. In fact, the frailty score seemed to be a better measure of surgical risk than the age of the patient or standard measures of surgical risk. The frailty score strongly predicted the risk of post-operative complications, or the need for nursing home care after surgery.

This study is a very useful advance in our understanding of surgical outcomes in older persons, but there is a need for much more research. Further studies need to better refine which measures of patient functioning best predict surgical outcomes. For example, this study did not measure cognitive functioning, which is undoubtedly a very important determinant of outcomes.

More importantly, while this study showed that it is important to assess functional ability before surgery, we need to know more about what happens to functional ability after surgery. This study advanced our understanding of commonly used surgical outcomes, but did not look at functional status outcomes. (ie, how long will my caregiver need to help with basic activities of daily living? How long before my walking is back to normal?)

We need studies in older persons that really provide an answer when the patient asks, "How will I do after surgery?"

Hopefully this study is the first of many from this team that begin to address these vital questions.

by: [Ken Covinsky]

Comments

Tim Cousounis said…
It's been my experience (professionally and personally) that much more is known than communicated (to patients and/or families).
It's been the slow rate of adoption of evidence-based practices, coupled with poor clinician-patient communications, which need to be improved.

Popular posts from this blog

Lost in Translation: Google’s Translation of Palliative Care to ‘Do-Nothing Care’

by: Cynthia X. Pan, MD, FACP, AGSF (@Cxpan5X)

My colleagues often ask me: “Why are Chinese patients so resistant to hospice and palliative care?” “Why are they so unrealistic?” “Don’t they understand that death is part of life?” “Is it true that with Chinese patients you cannot discuss advance directives?”

As a Chinese speaking geriatrician and palliative care physician practicing in Flushing, NY, I have cared for countless Chinese patients with serious illnesses or at end of life.  Invariably, when Chinese patients or families see me, they ask me if I speak Chinese. When I reply “I do” in Mandarin, the relief and instant trust I see on their faces make my day meaningful and worthwhile.

At my hospital, the patient population is about 30% Asian, with the majority of these being Chinese. Most of these patients require language interpretation.  It becomes an interesting challenge and opportunity, as we often need to discuss advance directives, goals of care, and end of life care options…

Elderhood: Podcast with Louise Aronson

In this week's podcast we talk with Louise Aronson MD, MFA, Professor of Geriatrics at UCSF about her new book Elderhood, available for purchase now for delivery on the release date June 11th.

We are one of the first to interview Louise, as she has interviews scheduled with other lesser media outlets to follow (CBS This Morning and Fresh Air with Terry...somebody).

This book is tremendously rich, covering a history of aging/geriatrics, Louise's own journey as a geriatrician facing burnout, aging and death of family of Louise's members, insightful stories of patients, and more.

We focus therefore on the 3 main things we think our listeners and readers will be interested in.

First - why the word "Elder" and "Elderhood" when JAGS/AGS and others recently decided that the preferred terminology was "older adult"?

Second - Robert Butler coined the term ageism in 1969 - where do we see ageism in contemporary writing/thinking?  We focus on Louise's…

Psychedelics: Podcast with Ira Byock

In this week's podcast, we talk with Dr. Ira Byock, a leading palliative care physician, author, and public advocate for improving care through the end of life.

Ira Byock wrote a provocative and compelling paper in the Journal of Pain and Symptom Management titled, "Taking Psychedelics Seriously."

In this podcast we challenge Ira Byock about the use of psychedelics for patients with serious and life-limiting illness.   Guest host Josh Biddle (UCSF Palliative care fellow) asks, "Should clinicians who prescribe psychedelics try them first to understand what their patient's are going through?" The answer is "yes" -- read or listen on for more!

While you're reading, I'll just go over and lick this toad.

-@AlexSmithMD





You can also find us on Youtube!



Listen to GeriPal Podcasts on:
iTunes Google Play MusicSoundcloudStitcher
Transcript
Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, I spy someone in our …